Healthcare Provider Details

I. General information

NPI: 1033650221
Provider Name (Legal Business Name): SUPRA MEDICAL GROUP II, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2017
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10300 SW 72ND ST STE 387
MIAMI FL
33173-3020
US

IV. Provider business mailing address

10300 SUNSET DR STE 101
MIAMI FL
33173-3038
US

V. Phone/Fax

Practice location:
  • Phone: 305-200-5210
  • Fax: 305-200-5780
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: KLEYDSON NEVES DA SILVA
Title or Position: MANAGER
Credential: OWNER
Phone: 786-205-4515